Pearls from Dr. Gary Schwartz

45 yo woman with metastatic melanoma found to have severe hypercalcemia to 19


  • Mechanisms of hypercalcemia in malignancy:

    1) Osteolytic metastases - seen commonly in breast cancer and multiple myeloma
    2) PTH-related protein secretion - seen commonly in nonmetastatic solid tumors and non-Hodgkin lymphoma
    3) Increased production of 1,25-dihydroxyvitamin D (calcitriol) - seen commonly in lymphomas
    4) Ectopic PTH secretion - described in ovarian carcinoma, SCLC and NSCLC, thyroid papillary carcinoma, and pancreatic malignancy

    Posted 06/20/16 11:24:55 AM by Anna Krigel

  • Management of severe hypercalcemia:

    - Volume expansion with isotonic saline to maintain urine output at 100 to 150ml/hr
    - Administration of calcitonin (4u/kg) every 6 to 12 hours for the first 48 hours
    - Bisphosphonate administration with zoledronic acid (4mg IV) or pamidronate (60 to 90mg) once

    Posted 06/20/16 11:31:13 AM by Anna Krigel

  • Developments in treatment of metastatic melanoma

    1) BRAF inhibition
    - common mutation in melanoma, present in 60% of cases, sun-induced oncogene
    - dabrafenib and vemurafenib cause a dramatic effect, though melanoma typically returns after several months because of a secondary mutation in downstream target MEK

    2) BRAF + MEK inhibition combination therapy
    - dabrafenib + trametinib improves progression free survival compared to dabrafenib plus placebo

    Posted 06/20/16 11:44:59 AM by Anna Krigel

  • Immunotherapy for metastatic melanoma

    1) CTLA-4 blockade
    - CTLA-4 found on surface of CD4 and CD8 lymphocytes, functions as a negative regulator of T cell activation
    - ipilimumab = first immune checkpoint inhibitor approved
    - CTLA-4 inhibitor monotherapy found to cause a phenomenon called pseudoprogression from inflammatory infiltration of tumor

    2) PD-1 blockade
    - transmembrane protein that binds to PD ligand-1 expressed on the surface of many tumor cells
    - pembrolizumab prolonged progression-free survival and overall survival in metastatic melanoma as compared to ipilimumab
    - nivolumab also prolonged overall survival in metastatic melanoma
    - PD-1 inhibitors also found to have less high-grade toxicity than CTLA-4 inhibitor

    3) CTLA-4 inhibitor combined with PD-1 inhibitor
    - combined nivolumab and ipilimumab improved progression-free survival compared to nivolumab alone in patients with PD-L1 negative tumors
    - strategy for treatment is to test patients for PD-L1 expression to see if monotherapy or combination therapy is needed
    - increased PD-L1 expression = treat with PD-1 inhibitor monotherapy

    Posted 06/20/16 02:38:22 PM by Anna Krigel

  • PD-1 inhibitors also being used in colon cancers that test for high microsatellite instability

    Posted 06/20/16 02:39:45 PM by Anna Krigel

  • Older woman w/ prior hx BRCA-related ovarian CA, now p/w atrial mass, found to be cardiac sarcoma


  • BRCA-related hereditary breast and ovarian CA syndromes

    Posted 11/22/16 09:12:47 AM by Matthew Cummings

  • Classic Chemotherapy/Onc Drug Toxicities

    Posted 11/22/16 09:38:51 AM by Matthew Cummings

  • Cardiac Tumors -- Clinical Manifestations
    Cardiac Sarcomas

    Posted 11/22/16 09:44:39 AM by Matthew Cummings

  • Olaratumab for soft-tissue sarcoma

    Posted 11/22/16 09:52:14 AM by Matthew Cummings

  • For further reading...

    Classic Chemotherapy-related Toxicities
    Olaratumab and doxorubicin vs. doxorubicin alone for soft tissue sarcoma (Lancet 2016)

    Posted 11/22/16 09:55:21 AM by Matthew Cummings

  • 73 y/o man with sciatic pain - found to have a chordoma


  • Osteogenic Sarcoma- Most Commonly in long bones (knee, shoulder)
    Ewing's Sarcoma

    Posted 02/21/17 10:28:56 AM by Adam Faye

  • Chordoma:


    Columbia Combined Cancer Panel:

    Posted 02/21/17 10:38:21 AM by Adam Faye

  • 45yo woman with history of melanoma p/w progression of disease


    70yo man with remote history of prostate cancer p/w weight loss and night sweats


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